Plasma Neutrophil Gelatinase-Associated Lipocalin Is Useful for Predicting Mortality in Critically Ill Patients.

Elevated neutrophil gelatinase-associated lipocalin (NGAL) occurs in a wide range of systemic diseases. This study examined the clinical utility of plasma NGAL to predict intensive care unit (ICU) and in-hospital mortality in critically ill patients. A total of 62 patients hospitalized in a mixed ICU were included; pNGAL, creatinine, and C-reactive protein (CRP) were assayed on four consecutive days (D1-D4) following ICU admission. APACHE II score (Acute Physiology and Chronic Health Evaluation) was calculated 24 h post-admission. ICU mortality reached 35% and in-hospital mortality was 39%. The median pNGAL at admission was 142.5 (65.6-298.3) ng/mL. pNGAL was significantly higher in non-survivors compared to survivors. The highest accuracy for ICU mortality prediction was achieved at the pNGAL cutoff of 93.91 ng/mL on D4 area under the curve (AUC) = 0.89; 95%CI 0.69-0.98 and for in-hospital mortality prediction was achieved at the pNGAL cutoff of 176.64 ng/mL on D3 (AUC = 0.86; 95%CI 0.69-0.96). The APACHE II score on ICU admission predicted ICU mortality with AUC = 0.89 (95%CI 0.79-0.96) and in-hospital mortality with AUC = 0.86 (95%CI 0.75-0.94). Although pNGAL on D1 poorly correlated with APACHE II (R = 0.3; p = 0.01), the combination of APACHE II and pNGAL on D1 predicted ICU mortality with AUC = 0.90 (95%CI 0.79-0.96) and in-hospital mortality with AUC = 0.95 (95%CI 0.78-0.99). Maximal CRP during study observation failed to predict ICU mortality (AUC = 0.62; 95%CI 0.49-0.74), but helped to predict in-hospital mortality (AUC = 0.67; 95%CI 0.54-0.79). Plasma NGAL with combination with the indices of critical illness is a useful biomarker for predicting mortality in heterogeneous population of ICU patients.

A Questionnaire Survey of Management of Patients with Aneurysmal Subarachnoid Haemorrhage in Poland.

BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) remains a potentially devastating threat to the brain with a serious impact on mortality and morbidity. We attempted to investigate correspondence between the current guidelines for aSAH management and real clinical practice in Poland. METHODS: A web-based questionnaire was performed between 03.2019 and 06.2019. Centres performing neuro-interventional radiology procedures and neuro-critical care were included (n = 29). One response from each hospital was recorded. RESULTS: In three (10.4%) centres, there was no clear protocol for an interventional treatment plan. Endovascular embolisation was predominantly used in 11 (37.9%) hospitals, and microsurgical clipping, in 10 (34.5%). A written protocol for standard anaesthetic management was established only in six (20.7%) centres for coiling and in five (17.2%) for microsurgical clipping. The diagnosis of cerebral vasospasm was based on transcranial Doppler as the first-choice method in seven (24.1%) units. "3-H therapy" was applied by 15 (51.8%) respondents, and "2-H therapy", by four (13.8%) respondents. In only eight (27.6%) centres were all patients with aSAH being admitted to the ICU. CONCLUSION: Many discrepancies exist between the available guidelines and clinical practice in aSAH treatment in Poland. Peri-procedural management is poorly standardised. Means must be undertaken to improve patient-oriented treatment and care.

Biomarkers Facilitate the Assessment of Prognosis in Critically Ill Patients with Primary Brain Injury: A Cohort Study.

Primary injuries to the brain are common causes of hospitalization of patients in intensive care units (ICU). The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system is widely used for prognostication among critically ill subjects. Biomarkers help to monitor the severity of neurological status. This study aimed to identify the best biomarker, along with APACHE II score, in mortality prediction among patients admitted to the ICU with the primary brain injury. This cohort study covered 58 patients. APACHE II scores were assessed 24 h post ICU admission. The concentrations of six biomarkers were determined, including the C-reactive protein (CRP), the S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), neutrophil gelatinase-associated lipocalin (NGAL), matrix metalloproteinase 9 (MMP-9), and tissue inhibitor of metalloproteinase 1 (TIMP-1), using commercially available ELISA kits. The biomarkers were specifically chosen for this study due to their established connection to the pathophysiology of brain injury. In-hospital mortality was the outcome. Median APACHE II was 18 (IQR 13-22). Mortality reached 40%. Median concentrations of the CRP, NGAL, S100B, and NSE were significantly higher in deceased patients. S100B (AUC = 0.854), NGAL (AUC = 0.833), NSE (AUC = 0.777), and APACHE II (AUC = 0.766) were the best independent predictors of mortality. Combination of APACHE II with S100B, NSE, NGAL, and CRP increased the diagnostic accuracy of mortality prediction. MMP and TIMP-1 were impractical in prognostication, even after adjustment for APACHE II score. S100B protein and NSE seem to be the best predictors of compromised outcome among critically ill patients with primary brain injuries and should be assessed along with the APACHE II calculation after ICU admission.

Plasma Matrix Metalloproteinase-9 and Tissue Inhibitor of Matrix Metalloproteinase-1 as Prognostic Biomarkers in Critically Ill Patients.

Matrix metalloproteinase 9 (MMP-9) plays an important role in inflammatory and pathological processes by enabling the inflow of leukocytes to the site of infection or tissue damage. MMP-9 and tissue inhibitor of metalloproteinase 1 (TIMP-1) have been described as potential prognostic biomarkers in various clinical settings. The aim of the study was to evaluate the usefulness of plasma levels of MMP-9 and TIMP-1 as well as the MMP-9/ TIMP-1 ratio in predicting the outcome in patients admitted to the intensive care unit (ICU). The study included 56 critically ill patients with multiple organ failure. Plasma levels of MMP-9 and TIMP-1 were determined on hospitalization day 1, 2, 3 and 7. Nineteen (35.7%) patients died. The level of TIMP-1 was statistically significantly higher on day 1 and 7 of hospitalization in non-survivors, as compared to survivors (p=0.01). A statistically significant positive correlation was found between MMP-9 and TIMP-1. The MMP-9/TIMP-1 ratio was comparable in both groups during of observation (0.62 on day 1). The MMP-9/TIMP-1 ratio was positively correlated with the level of lactate and negatively correlated with platelet count. Likewise, TIMP-1 was positively correlated with the level of lactate. The level of MMP-9 was higher in the non-survivor group only on day 7 of observation. In conclusion, although TIMP-1 and MMP-9 concentrations were higher in non-survivors and the MMP-9/TIMP-1 ratio was related to some parameters of critical illness, further research is needed to verify whether they can serve as reliable biomarkers for early prognostication of ICU patients.

Serum levels of the S100B protein and neuron-specific enolase are associated with mortality in critically ill patients.

INTRODUCTION: Evaluation of the prognostic potential of the S100B protein and neuron-specific enolase (NSE) as predictors of mortality in critically ill patients in intensive care units (ICU). MATERIALS AND METHODS: The study was conducted on 62 patients. Basic clinical variables and blood samples for S100B and NSE level testing were obtained during the first four days after admission. Mortality was described as the patient's death during hospitalization in the ICU. RESULTS: 35% of the patients had died. The level of S100B and NSE was significantly higher in non-survivors in comparison with survivors (p=0.007 and p=0.02, respectively). Mortality risk was significantly higher in patients with higher levels of biomarkers than the reference values for S100B (OR 9.00; 95% CI 2.38-33.99; p<0.001) as well as for NSE (OR 5.75; 95%CI 1.31-25.27; p=0.016). Receiver operating characteristic proved that S100B is a better mortality predictor than NSE (AUC 0.76 for S100B and 0.68 for NSE). From all the other variables, the Apache II score turned out to be the only significant predictor of mortality (AUC 0.88). CONCLUSION: There is a significant correlation between mortality in the ICU and increased serum concentration of S100B and NSE. This correlation is stronger for S100B. Testing for serum levels of S100B and NSE may be useful for prediction of treatment outcomes in the ICU patients.

A comparison of subhypnotic doses of propofol and midazolam during spinal anaesthesia for elective Caesarean section.

BACKGROUND: This study compared two types of sedation in pregnant women receiving subarachnoid anaesthesia for elective Caesarean section. METHODS: This prospective randomised study included 56 women. Patients were sedated with propofol (PROP group, n = 27) or midazolam (MID group, n = 29) via intravenous infusion after extraction of the foetus. The following parameters were assessed at five-minute intervals: degree of sedation, heart rate, arterial pressure, ECG recording and arterial haemoglobin oxygen saturation. Moreover, we recorded drug doses, changes in infusion rates to ensure a desirable degree of sedation and adverse side effects. The maternal recall of delivery and satisfaction with sedation were also evaluated. RESULTS: The incidence of increased sedative infusion rates was higher in the PROP group (59.3% vs. 37.9%). In contrast, decreased infusion rates were observed in the MID group (41.4% vs. 29.6%). After the initial dose, a desirable level of sedation was easier to obtain in the PROP group (77.7% vs. 55.1%), whereas excessive sedation was noted more frequently in the MID group (34.5% vs. 11.5%). The deepest degree of sedation was found in 2 PROP patients and 1 MID patient. In the PROP group, excessive sedation was rapidly alleviated by reducing the infusion rate. In the MID group, excessive sedation was observed throughout the examination, despite reduced infusion rates. No significant intergroup differences were found for desired sedation levels. The mean heart rate and arterial pressure were lower in the PROP group. In the MID group, only 5% of patients developed an elevated systolic RR. No ECG alterations were observed in any patient. A haemoglobin oxygen saturation level below 92% was found in 1 patient from each group. Logorrhoea was characteristic in the PROP group (44.4%). The incidence of nausea and vomiting were higher in the MID group. Other side effects (e.g., headache, backache, erythema and chills) were observed in a subset of patients from both groups. In the MID group, birth recall was significantly lower (82.8% vs. 96.3%). Full satisfaction with sedation was declared by 89.6% of MID patients and 92.6% of PROP patients. CONCLUSIONS: Midazolam and propofol induce effective and safe sedation in patients receiving subarachnoid anaesthesia for Caesarean section. Propofol appears to be more useful for Caesarean section sedation when compared with midazolam because of its shorter action, antiemetic effects and better maternal recall of foetal delivery.

The sitting position during neurosurgical procedures does not influence serum biomarkers of pulmonary parenchymal injury.

BACKGROUND: The sitting position during neurosurgical operations predisposes to air penetration through veins and the movement of the air through the pulmonary circulation. Contact of an air bubble with the endothelium can lead to acute lung injury. The presence of specific pulmonary proteins in the plasma such as surfactant protein D (SP-D) and Clara cell protein (CC16) is a biomarker of damaging processes at the air-blood barrier. The aim of our study was to examine the hypothesis that the level of investigated pulmonary biomarkers in plasma is higher in patients operated on in the sitting position. METHODS: The study included patients undergoing planned neurosurgical operations, who were divided into two groups: the sitting group (40 patients, operated on in the sitting position) and the supine group (24 patients, operated in the supine position). After the operation blood samples were drawn, centrifuged, frozen and stored until analyses were conducted. The determination of the SP-D and CC16 levels was performed using an ELISA test. Air embolism (VAE) was defined as a sudden drop in etCO2 of more than 2 mmHg and the presence of air bubbles in the aspirated blood from the central cannula. In all patients, the number of hospitalization days in the postoperative period was calculated. RESULTS: There were no differences in the average levels of SP-D between the groups (the mean in the sitting group was 95.56 ng/mL and the mean in the supine group was 101.21 ng/mL). The average levels of CC16 were similar in both groups as well (6.56 ng/mL in the sitting group and 6.79 ng/mL in the supine group). There was a statistically significant positive correlation between SP-D and CC16 values in both groups. VAE was diagnosed clinically in 12.5% of cases in the sitting group without a significant increase in SP-D and CC16 levels. On average, patients in both groups were discharged from the hospital within 9 days of surgery. CONCLUSION: The sitting position and intraoperative VAE during neurosurgical procedures do not affect the concentration of plasma biomarkers of pulmonary parenchymal injury such as SP-D and CC16.

[Anaesthesiology in the Polish Armed Forces in the West during World War II]. / Anestezjologia w Polskich Silach Zbrojnych na Zachodzie.

Until the outbreak of WW II, anaesthesiology, as a separate specialty, did not exist in Poland. After the fall of Poland, a large section of the Polish Armed Forces was evacuated to France and after that, to the UK, where Polish military physicians had a unique opportunity to obtain training in modern anaesthesia. The first regular courses were established at the University of Edinburgh. After WW II, doctor Stanislaw Pokrzywnicki, a pioneer of Polish anaesthesiology, who was trained by Sir Robert Macintosh, and doctor Boleslaw Rutkowski, an anaesthesiologist in London, returned to Poland and started regular services. This led to the registering of anaesthesiology as a separate specialty in 1951. In the article, the wartime and post-war stories of the first Polish anaesthesiologists are presented.

[Surfactant protein D as a biomarker for lung injury]. / Bialko D surfaktantu jako biomarker uszkodzenia pluc.

Respiratory distress and the need for mechanical ventilation, have been the most common reasons for ITU hospitalization. Pulmonary pathology is sometimes difficult to diagnose and differentiate; therefore we are on a continuous search for diagnostic tools and markers. It has been suggested that in patients intubated for acute lung injury, lower concentrations of surfactant proteins A and D in bronchoalveolar fluid and higher concentrations in the plasma are associated with more severe lung injury and worse clinical outcomes. Surfactant protein D (SP-D) plays a crucial role in defense mechanisms and immunomodulation, binding with various pathogens such as bacteria, fungi and viruses. SP-D is a valuable marker in ARDS and other specific and non-specific pulmonary pathologies, and may find a place as a valuable marker of the severity of disease.

[Endoscopic transsphenoidal treatment of pituitary adenomas]. / Endoskopowe leczenie gruczolaków przysadki.

BACKGROUND AND PURPOSE: The aim of this study is to present a new endoscopic transnasal transsphenoidal method of surgical treatment of pituitary adenomas and to evaluate the results and complications of the method. MATERIAL AND SURGICAL TECHNIQUE: From October 2001 to June 2003 in the Department of Neurosurgery of the Medical University of Silesia in Katowice 88 operations of pituitary adenomas were performed using the transnasal transsphenoidal endoscopic method. The group of patients consisted of 50 females and 38 males. The youngest patient was 11 years old and the oldest was 79 years old. Patients were operated on using the 4-mm diameter endoscope with 0- and 30-degree angled lenses, using a method of operation according to Jho and Carrau with own modifications. At the time of surgery the operation team included 2 neurosurgeons, an anesthesiologist and a laryngologist. RESULTS: In the group of 51 nonfunctioning adenomas, in 32 cases we obtained the total removal of the tumor, which amounts to 63%. Among 37 of hyperfunctioning adenomas there were 11 prolactinomas, 19 GH secreting adenomas and 7 ACTH secreting adenomas. In all cases of prolactinomas the tumor was removed totally and in the cases of GH secreting adenomas and ACTH secreting adenomas the total removal of the tumor was performed in 58% and 86% of the cases, respectively. One patient within our group died after the operation. It was the patient with a huge nonfunctioning macroadenoma, with hydrocephalus and preoperative disturbances of consciousness. The permanent diabetes insipidus occurred in 2 cases, which amounts to 2.3% of all operated patients. In this group we noticed the intraoperative CSF leakage in 20 cases but we did not observe the postoperative CSF leakage or any rhinological complications. CONCLUSIONS: The endoscopic transnasal transsphenoidal approach is an efficient method of surgical treatment of pituitary adenomas. The advantage of this method is low invasiveness and a small number of serious complications.

Non-neoplastic, degenerative brain pathologies and fibroses diagnosed on the basis of ultra-small samples obtained by stereotactic biopsy.

Brain biopsy and other stereotactic procedures have evolved over the last decades. Recently, the morbidity and mortality decreased radically along with an increase in the number of successful histopathological diagnoses. Therefore, applications of appropriate treatments in neoplastic brain pathologies are now possible, especially of those located in deep regions. Stereotactic biopsy may also be used as a diagnostic method followed by appropriate management in conditions where a non-neoplastic pathology is suspected. Between December 2000 and February 2004, we performed 116 stereotactic procedures based on the system of stereotactic planning and Brain-Lab treatment, which was equipped with automatic CT/MR image fusion software. In this report, we have focused on 10 cases of non-neoplastic brain pathologies diagnosed on the basis of ultra-small samples obtained from stereotactic biopsy. Among them there were 4 cases of gliosis, 3 cases of brain degenerative disorders, 2 cases of hippocampal fibroses, and 1 case of normal brain tissue. We have presented all these cases in detail by discussing their histology, clinical manifestations, localisation, management and follow-up.

[Multimodal intraoperative electrophysiological monitoring during cerebellopontine angle tumor surgery. Benefit or loss?]. / Wielomodalne sródoperacyjne monitorowanie elektrofizjologiczne w trakcie operacji guzów kata mostowo-mózdzkowego. Zysk czy strata?

In the Neurosurgery Department, Silesian University School of Medicine, continuous monitoring of selected neurophysiological functions of the central and peripheral nervous system was introduced in 1998 as a routine procedure in cerebellopontine angle surgery and some other operations performed in the petroclival region. Such benefits from this method as increased patient safety, availability of information about dynamic changes in the monitored structures, and the possibility of cranial nerves localization using stimulation in the operating area, are quite obvious. The paper presents results of a detailed statistical analysis of the amount of time required for preparation and for operating in 174 cerebellopontine angle tumor surgeries performed in the years 1986-2002 with (group M) and without (group BM, before the year 1998) intraoperative monitoring. Subgroups distinguished according to the histological type of tumor were evaluated. Out of 95 procedures performed in group M, 57 were operations of acoustic neurinoma cases, 15 meningiomas, 8 cases of epidermal cyst, and 15 other growth processes in the cerebellopontine angle region. Among 79 operations in group BM, there were 57 cases of acoustic neurinoma, 4 cases of meningioma, 8 cases of epidermal cyst, and 10 of other types of neoplastic growth. In group M as compared to group BM the pre-op. preparation time was found to be significantly longer in cases of the VIII-th nerve neurinoma, and of other tumors. No statistically significant differences in the amount of operating time in were found between any of the subgroups. Both radicality of tumor removal and facial nerve status have clearly improved since intraoperative monitoring was introduced.

[Endoscopic ventriculostomy of the third ventricle in adults. Own experience]. / Wentrikulostomia endoskopowa komory III u doroslych. Doswiadczenia wlasne.

Only few reports can be found on endoscopic third ventriculostomy (ETV) in the Polish literature, and the majority of other reports concern paediatric or mixed population. This has induced the authors to report their experience with ETV in adults, reporting the results and discussing the usefulness and effectiveness of this procedure, causes of complications and failure. ETV was carried out in 20 patients aged over 18 years in a two-year period, beginning in 1999. In 13 cases (64%) the cause was external compression of CSF system by tumour leading to hydrocephalus. In 3 cases aqueduct stenosis was producing hydrocephalus, in 3 cases arachnoid cyst, perisellar or situated in posterior part of the third ventricle, was the cause, and in one case colloidal cyst of the third ventricle. The outcome were analysed according to clinical and radiological criteria finding that the ETV was successful in 90% of cases by clinical criteria, and in 88% by radiological criteria. Only unimportant clinical complications were reported without major consequences. It is concluded that ETV is a very useful method for hydrocephalus treatment in adults, especially if caused by blockade of CSF pathways by tumour or arachnoid cysts in the vicinity of the third ventricle.